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State Medicaid Expansion Tobacco Cessation Coverage and Number of Adult Smokers Enrolled in Expansion Coverage — United States, 2016

Summary

What is already known about this topic?

Medicaid enrollees smoke cigarettes at a higher rate than do privately insured U.S. residents. States that expand Medicaid eligibility are able to extend coverage to large numbers of adult smokers who are not eligible for traditional Medicaid cessation coverage, thereby substantially increasing the potential impact of Medicaid cessation coverage.

What is added by this report?

By expanding Medicaid eligibility under the Affordable Care Act, 32 states have extended Medicaid cessation coverage to about 2.3 million adult smokers who were not previously eligible for Medicaid. All 32 of these states covered some cessation treatments for all Medicaid expansion enrollees. Nine states covered all nine cessation treatments considered in this study for all Medicaid expansion enrollees, and 19 states covered all seven FDA-approved cessation medications for all enrollees. All 32 states imposed one or more barriers to accessing at least one cessation treatment for at least some enrollees.

What are the implications for public health practices?

States that have expanded Medicaid can take further steps to help smokers quit by covering proven cessation treatments more fully, removing barriers to accessing covered treatments, making Medicaid enrollees and their health care providers aware of these treatments, and monitoring use of these treatments.

In 2015, 27.8% of adult Medicaid enrollees were current cigarette smokers, compared with 11.1% of adults with private health insurance, placing Medicaid enrollees at increased risk for smoking-related disease and death (1). In addition, smoking-related diseases are a major contributor to Medicaid costs, accounting for about 15% (>$39 billion) of annual Medicaid spending during 2006–2010 (2). Individual, group, and telephone counseling and seven Food and Drug Administration (FDA)–approved medications are effective treatments for helping tobacco users quit (3). Insurance coverage for tobacco cessation treatments is associated with increased quit attempts, use of cessation treatments, and successful smoking cessation (3); this coverage has the potential to reduce Medicaid costs (4). However, barriers such as requiring copayments and prior authorization for treatment can impede access to cessation treatments (3,5). As of July 1, 2016, 32 states (including the District of Columbia) have expanded Medicaid eligibility through the Patient Protection and Affordable Care Act (ACA),*,† which has increased access to health care services, including cessation treatments (5). CDC used data from the Centers for Medicare and Medicaid Services (CMS) Medicaid Budget and Expenditure System (MBES) and the Behavioral Risk Factor Surveillance System (BRFSS) to estimate the number of adult smokers enrolled in Medicaid expansion coverage. To assess cessation coverage among Medicaid expansion enrollees, the American Lung Association collected data on coverage of, and barriers to accessing, evidence-based cessation treatments. As of December 2015, approximately 2.3 million adult smokers were newly enrolled in Medicaid because of Medicaid expansion. As of July 1, 2016, all 32 states that have expanded Medicaid eligibility under ACA covered some cessation treatments for all Medicaid expansion enrollees, with nine states covering all nine cessation treatments for all Medicaid expansion enrollees. All 32 states imposed one or more barriers on at least one cessation treatment for at least some enrollees. Providing barrier-free access to cessation treatments and promoting their use can increase use of these treatments and reduce smoking and smoking-related disease, death, and health care costs among Medicaid enrollees (4,6–8).

A Healthy People 2020 objective (TU-8) calls for all state Medicaid programs to adopt comprehensive coverage of smoking cessation treatments.§ A previous study reported on state Medicaid coverage of cessation treatments during 2014–2015 in the population traditionally eligible for Medicaid coverage (9), but cessation coverage has not been reported among the population newly eligible for Medicaid expansion coverage in the 32 states (including the District of Columbia) that expanded Medicaid eligibility through ACA as of July 1, 2016. These states elected to expand coverage to a new eligibility group of adults aged <65 years known as the Medicaid expansion population (also known as the VIII group).

To estimate the number of adult cigarette smokers enrolled in Medicaid expansion coverage, 2014 BRFSS¶ estimates of state-specific smoking prevalence among self-reported Medicaid enrollees were multiplied by MBES** enrollment data for December 2015. Newly eligible Medicaid enrollees were defined as persons who were newly enrolled in Medicaid because of ACA Medicaid expansion. Some states expanded Medicaid eligibility to varying extents before ACA was enacted. The overall Medicaid expansion population estimates (Table 1) include persons who enrolled in Medicaid because of these previous state expansion actions, as well as persons who enrolled in Medicaid because of state Medicaid expansions under ACA. The newly eligible Medicaid population estimates include the latter group only.

To assess cessation coverage available to the state Medicaid expansion population as of July 1, 2016, the American Lung Association collected data on coverage of, and barriers to accessing, all evidence-based cessation treatments except telephone counseling†† (a total of nine treatments) for state Medicaid expansion populations. The American Lung Association compiled data from Medicaid member websites and handbooks; Medicaid provider websites and handbooks; policy manuals; plan formularies and preferred drug lists; Medicaid state plan amendments; and relevant regulations and legislation. Personnel from state Medicaid agencies and health departments or other state government agencies were consulted to confirm the accuracy of collected information, retrieve missing documents, and reconcile discrepancies. Data were collected during July 19–August 18, 2016.

As of December 2015, approximately 3.3 million adult cigarette smokers were enrolled in Medicaid expansion coverage, including approximately 2.3 million adults who were newly eligible for Medicaid expansion coverage (Table 1). The number of adult smokers enrolled in Medicaid expansion coverage ranged from 2,567 in Alaska to 618,395 in New York; the number of newly eligible adult smokers enrolled in this coverage ranged from 2,567 in Alaska to 291,351 in Pennsylvania (Table 1).

As of July 1, 2016, nine of the 32 states that have expanded Medicaid eligibility (Colorado, Connecticut, Indiana, Massachusetts, Minnesota, North Dakota, Ohio, Pennsylvania, and Vermont) covered all nine cessation treatments for all Medicaid expansion enrollees (Table 2). Of the 32 states, 17 states covered individual counseling for all Medicaid expansion enrollees, 11 covered group counseling for all enrollees, and 19 covered all seven FDA-approved cessation medications for all enrollees. All 32 states imposed at least one barrier (e.g., copayments or prior authorization) on at least one treatment for at least some enrollees (Table 3). Six states required copayments for at least one cessation treatment for all enrollees, with an additional seven states requiring copayments for some enrollees. Twelve states required prior authorization to obtain at least one cessation treatment for all enrollees, with an additional 14 states requiring prior authorization for some enrollees.

Discussion

Under the Medicaid expansion provision of ACA, states can expand Medicaid eligibility to include adults aged <65 years with incomes ≤138% of the Federal Poverty Level.§§,¶¶ As of July 1, 2016, 32 states have expanded Medicaid eligibility, a step which has made Medicaid cessation coverage available to approximately 2.3 million adult smokers who were not previously eligible for Medicaid. Moreover, all of these states covered some cessation treatments for all Medicaid expansion enrollees, and 19 states covered all seven FDA-approved cessation medications for all enrollees. However, only nine states covered all nine cessation treatments, and all 32 states imposed one or more barriers to accessing cessation treatments for at least some enrollees. Several states, including Michigan and Minnesota, have made notable progress in removing barriers to cessation coverage for both their expansion and traditional (i.e., nonexpansion) Medicaid populations in recent years. Other states have made more recent progress in this regard. For example, Maryland removed copayments for cessation medications for enrollees in both expansion and traditional Medicaid, effective October 21, 2016. In September 2016, California enacted legislation requiring the state Medicaid program to cover a comprehensive cessation benefit for both the expansion and traditional Medicaid populations, effective January 1, 2017. Providing and promoting evidence-based cessation coverage has been found to be a cost-effective way to help smokers quit. Among the Medicaid population in Massachusetts, an evidence-based, heavily promoted Medicaid cessation benefit was associated with a reduction in smoking prevalence, from 38.3% to 28.3% over a 3-year period (7). For each dollar spent on the benefit over a 3-year period, an estimated $3.12 in medical savings occurred from averted cardiovascular hospitalizations alone (4).

With regard to tobacco cessation coverage, Medicaid expansion coverage is subject to different ACA provisions than traditional Medicaid coverage (5). Unlike traditional Medicaid coverage, Medicaid expansion coverage is subject to Section 1001 of ACA, which requires coverage without cost-sharing of preventive services receiving an A or B rating from the U.S. Preventive Services Task Force (USPSTF) (5). Tobacco cessation intervention has received an A-grade from USPSTF.***,††† Guidance issued by the departments of Health and Human Services, Labor, and Treasury in May 2014 defines how this provision applies to cessation coverage.§§§ To assist with compliance with Section 1001, CMS is contacting states to ensure that they understand the previous guidance and to provide technical assistance for states to achieve compliance. Several states that currently require copayments for some cessation treatments for Medicaid expansion enrollees have indicated that they are planning to remove this requirement.

More comprehensive state Medicaid coverage of cessation treatments is associated with increased use of cessation medications and increased quit rates among smokers enrolled in Medicaid (6,8). Moreover, removing barriers such as copayments, which pose a financial obstacle, and prior authorization, which can delay accessing services unless a process is in place to expedite authorization, further increases access to these treatments (3,5). Communicating to smokers and health care providers that cessation treatments are covered is also important to ensure that they are aware of and use covered treatments (5,7). A recent study found that only approximately 10% of Medicaid enrollees who smoked received a prescription for a tobacco cessation medication in 2013, with wide variation in use of cessation medications across states (10). Medicaid cessation coverage has the greatest effect when it is available to large numbers of smokers and is widely used (5,7).

The findings in this report are subject to at least four limitations. First, enrollment estimates were drawn from a new CMS reporting system whose primary purpose is to allow states to claim the enhanced Medicaid expansion federal matching rate; this system was missing information for seven expansion states for the assessment period. Second, the state smoking prevalence estimates were based on respondents who reported that they smoked and were enrolled in Medicaid; these estimates were not available for three states, and the relevant BRFSS question did not distinguish between traditional and Medicaid expansion coverage. In addition, 2014 smoking prevalence estimates were applied to December 2015 enrollment data to generate estimates of smokers enrolled in Medicaid expansion. Third, in cases where official coverage documents were not publicly available, were outdated, or conflicted with one another, state government personnel were consulted to provide additional documentation or resolve discrepancies; this information might be inaccurate in some cases. Finally, cessation coverage can vary widely across Medicaid expansion managed care plans, making it challenging to determine coverage.

The 32 states that have expanded Medicaid eligibility under ACA are providing Medicaid cessation coverage to approximately 2.3 million adult smokers who were not previously eligible for Medicaid. These states can take further steps toward helping these smokers quit by more fully covering cessation treatments, removing barriers to accessing covered treatments, making Medicaid enrollees and providers aware of these treatments, and monitoring use of these treatments (3,5–7). State Medicaid programs that take these actions can substantially reduce tobacco use and tobacco-related disease and health care costs among a vulnerable population (4–7). Opportunities exist for the 19 states that have not expanded Medicaid eligibility to reduce smoking among low-income adults by making their cessation coverage more broadly available. Providing barrier-free access to cessation treatments and promoting their use are important components of a comprehensive approach to reducing tobacco use (3,5–7).

† Coverage for the adult expansion population must be offered through an alternative benefit plan. States generally have expanded coverage in one of two ways: by extending traditional Medicaid coverage to the Medicaid expansion population or by creating a benefit package that is not aligned with the state’s traditional Medicaid state plan and using managed care for the expansion population. States can also provide subsidies to this population that are used to purchase coverage offered in the state or federally facilitated marketplace created by the Patient Protection and Affordable Care Act.

¶ Data were obtained from the Behavioral Risk Factor Surveillance System (BRFSS) 2014 health care access module (http://www.cdc.gov/brfss/). Smoking prevalence estimates were calculated for 2014 BRFSS respondents aged 18–64 years who reported the following: 1) smoking ≥100 cigarettes during their lifetimes and smoking every day or some days at the time of the interview, and 2) having Medicaid or another state program as the primary source of their health care coverage. The relevant BRFSS question did not distinguish between traditional and expansion Medicaid coverage.

†† Telephone cessation counseling is available free to callers to state quitlines (including Medicaid enrollees) in all 50 states and the District of Columbia through the national quitline portal 1-800-QUIT-NOW, and therefore is not included in this report. In June 2011, the Centers for Medicare & Medicaid Services (CMS) announced that it would offer a 50% federal administrative match to state Medicaid programs for the cost of state quitline counseling provided to Medicaid enrollees. Although not discussed in this report, some state Medicaid programs cover or otherwise provide access to telephone counseling for at least some Medicaid enrollees.

¶¶ Although a June 2012 Supreme Court ruling held that a state cannot lose federal funding for its existing Medicaid program if it does not participate in the expansion, financial incentives exist for all states to expand eligibility for Medicaid coverage (National Federation of Independent Business, et al. v. Kathleen Sebelius, Secretary of Health and Human Services, et al.; 132 S. Ct. 2566 [2012]).

US Public Health Service. Treating tobacco use and dependence: 2008 update—clinical practice guideline. Rockville, MD: US Department of Health and Human Services, US Public Health Service; 2008. https://www.ncbi.nlm.nih.gov/books/NBK63952/

Richard P, West K, Ku L. The return on investment of a Medicaid tobacco cessation program in Massachusetts. PLoS One 2012;7:e29665. CrossRefPubMed

TABLE 1. Estimated number of current smokers aged 18–64 years in Medicaid Expansion—32 states,* December 2015

State

Adults enrolled in Medicaid

Medicaid smoking prevalence¶

Adult smokers in Medicaid expansion

Total no.†

No. in Medicaid expansion†

No. newly eligiblein Medicaid expansion†,§

Total no.**

No. newly eligible**

Alaska

124,883

8,500

8,500

30.2

2,567

2,567

Arizona

1,873,397

412,957

105,711

30.4

125,622

32,157

Arkansas

919,768

291,602

266,741

NA

NA

NA

California

NA

NA

NA

NA

NA

NA

Colorado

NA

NA

NA

27.4

NA

NA

Connecticut

840,619

200,988

186,967

37.0

74,426

69,234

Delaware

210,636

60,006

9,280

37.4

22,460

3,474

District of Columbia

243,612

61,946

61,946

40.7

25,224

25,224

Hawaii

313,126

107,485

33,427

NA

NA

NA

Illinois

2,869,749

641,439

616,265

35.8

229,892

220,869

Indiana

1,244,321

361,687

222,364

48.3

174,550

107,313

Iowa

585,978

146,310

135,963

43.4

63,499

59,008

Kentucky

1,274,166

439,044

439,044

50.1

219,785

219,785

Louisiana

1,444,601

NA

NA

35.9

NA

NA

Maryland

1,061,749

231,484

231,484

30.3

70,140

70,140

Massachusetts

1,805,041

384,390

0

32.8

126,157

0

Michigan

2,287,620

613,761

579,378

40.9

250,844

236,792

Minnesota

1,186,498

208,492

207,683

32.6

68,031

67,767

Montana

138,970

NA

NA

51.3

NA

NA

Nevada

NA

NA

NA

35.6

NA

NA

New Hampshire

187,999

49,040

48,759

48.8

23,946

23,809

New Jersey

NA

NA

NA

23.0

NA

NA

New Mexico

840,108

235,425

235,425

30.4

71,522

71,522

New York

5,768,918

2,276,859

285,564

27.2

618,395

77,559

North Dakota

NA

NA

NA

43.8

NA

NA

Ohio

2,930,308

653,434

607,139

47.4

309,466

287,541

Oregon

1,055,080

518,904

452,269

35.8

185,768

161,912

Pennsylvania

2,670,350

603,335

547,962

53.2

320,793

291,351

Rhode Island

279,851

59,280

59,280

29.8

17,671

17,671

Vermont

207,146

60,678

0

36.8

22,323

0

Washington

1,813,800

592,114

577,422

34.2

202,562

197,536

West Virginia

554,210

174,999

174,999

48.9

85,627

85,627

Total

34,732,504

9,394,159

6,093,572

NR

3,311,270

2,328,858

Abbreviations: NA = not available; NR = not reported.* Includes the District of Columbia.† Enrollment estimates were drawn from the Centers for Medicare and Medicaid Services Medicaid Budget and Expenditure System (MBES) CMS 64 Total Medicaid Enrollees – VIII Group Break Out Report, October–December 2015, Updated June 2016 (https://www.medicaid.gov/medicaid/program-information/downloads/cms-64-enrollment-report-oct-dec-2015.pdf). MBES was missing information for seven expansion states for the period in question.§ The total VIII group category includes persons who enrolled in Medicaid because of actions in some states that expanded Medicaid eligibility before enactment of the Patient Protection and Affordable Care Act (ACA) and persons who enrolled in Medicaid because of state Medicaid expansions under ACA. The total VIII group newly eligible category only includes the latter group.¶ Data were obtained from the Behavioral Risk Factor Surveillance System (BRFSS) 2014 health care access module (http://www.cdc.gov/brfss/). Smoking prevalence estimates were calculated for 2014 BRFSS respondents aged 18–64 years who reported: 1) smoking ≥100 cigarettes during their lifetimes and smoking every day or some days at the time of the interview, and 2) having Medicaid or another state program as the primary source of their health care coverage. The relevant BRFSS question did not distinguish between traditional and expansion Medicaid coverage.** BRFSS smoking prevalence estimates from 2014 were applied to December 2015 enrollment data to generate estimates of smokers with expansion Medicaid coverage. Although one decimal point prevalence estimates are reported here, two decimal point prevalence estimates were used in calculating the total and newly eligible numbers of smokers in the VIII group.

Abbreviations: NA = not available; V = varies by plan.* Includes the District of Columbia.† Barriers apply to one or more cessation treatments.§ Refers to a requirement that a person try and fail to quit with one cessation medication before being able to access another cessation medication.

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